According to the American Heart Association, cardiovascular disease (CVD) is America's leading health problem and the leading cause of death. At least 80 million people in this country suffer from some form of CVD. In this week's issue, you will discover new uses for two existing medications in the treatment of a certain type of heart disease as well as the results of a study of doctors' attitudes toward obese patients.

Plus, learn how employers can leverage health plan support for smoking cessation.

Your colleague in the business of
healthcare,
Jessica Papay
Editor, Disease Management Update

Two medications commonly used to treat high blood pressure appear to be effective in treating a common type of heart disease known as stable ischemic heart disease, according to a new comparative effectiveness review funded by HHS' AHRQ. Treatment featuring the two medications — inhibitors of angiotensin-converting enzyme, or ACE inhibitors, and angiotensin receptor blockers, or ARBs — can lead to a reduction in death, risk of heart attack, risk of stroke and fewer hospitalizations for heart failure for patients suffering from stable ischemic heart disease, researchers found. However, the drugs have risks of their own. Risks associated with ACE inhibitors include a persistent cough, sudden fainting, too much potassium in the blood and dangerously low blood pressure (hypotension). Risks associated with ARBs include too much potassium in the blood and low blood pressure.

Stable ischemic heart disease occurs when the flow of oxygen-rich blood to the heart is reduced because of narrowed or blocked arteries. Symptoms of stable ischemic heart disease include decreased tolerance of exercise and severe chest pain on exertion (known as angina), which afflicts about 9 million U.S. adults. Long-term risks of stable ischemic heart disease include heart failure and heart attack. Overall, heart disease is among the nation's most common and deadly illnesses, afflicting nearly 80 million Americans and killing nearly 2,400 every day. Standard treatment of stable ischemic heart disease consists of a modification of diet, exercise and medications including aspirin, anti-cholesterol drugs, nitroglycerin and beta blockers. These can keep the disease from worsening. However, while standard treatment usually alleviates chest pain, it is not universally successful in reducing risk of heart failure or heart attack. For patients with advanced stable ischemic heart disease, treatment can include heart surgery or angioplasty.

The AHRQ report also found that patients with stable ischemic heart disease who take an ACE inhibitor in addition to standard treatment can reduce the likelihood of several negative outcomes, including death from heart attack or heart failure, non-fatal heart attacks, hospitalization for heart failure, and revascularization (surgeries that reroute blood to the heart). Patients who take an ARB in addition to standard medications can reduce their risk of death from a heart-related cause, heart attack or stroke. While some patients and clinicians pursue a course of treatment using both ACE inhibitors and ARBs, the report found that combined treatment does not show any benefit over an ACE inhibitor alone and that risks include fainting, diarrhea, low blood pressure and kidney problems.

Doctors have less respect for their obese patients than they do for patients of normal weight, a new study by Johns Hopkins researchers suggests. The findings raise questions about whether negative physician attitudes about obesity could be affecting the long-term health of their heavier patients. As patients had higher body mass index (BMI), physicians reported lower respect for them, according to the study. In a group of 238 patients, each 10-unit increase in BMI was associated with a 14 percent higher prevalence of low patient respect.

Previous studies have shown that when physicians respect their patients, patients get more information from their doctors. Some patients who don’t feel respected may avoid the healthcare system altogether, surveys and focus groups have shown. One limitation of the new study is that it was unable to link low physician respect directly to poor health outcomes.

According to Mary Margaret Huizinga, M.D., M.P.H., an assistant professor of general internal medicine at the Johns Hopkins University School of Medicine, “the next step is to really understand how physician attitudes toward obesity affect quality of care for those patients, to really understand how this affects outcomes. If a doctor has a patient with obesity and has low respect for that person, is the doctor less likely to recommend certain types of weight loss programs or to send her for cancer screening? We need to understand these things better.” Ultimately, says Dr. Huizinga, physicians need to be educated that obesity bias and discrimination exist. One good place to start would be in medical school, where she says little is taught to reduce or compensate for these negative attitudes. “Awareness of their own biases can lead to an alteration of behavior and sensitivity that they need to watch how they act toward patients,” she says.

Collaborative patient care models that empower the primary care nurse to communicate patient needs to physicians has not only improved patient care and outcomes but also fostered a cultural change at Hackensack University Medical Center, explains Lenore Blank, a nurse practitioner and administrative manager of HUMC's heart failure and pulmonary hypertension team. Her team is part of Pursuing Perfection, a healthcare quality initiative from the Institute of Healthcare Improvement. As HUMC creates the partnerships mandated by Pursuing Perfection, it is extending the knowledge and benefits they've gained with other organizations — and reducing hospital readmissions in the process.

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Jennifer Hidding, former director of interactive health management of consumer solutions for OptumHealth.

Question: If you were a hospital with 4,000 employees, and you had one on-site health coach, where would you start? Would you start with DM, chronic DM or more general health coaching for lifestyle?

Response: I would look at the next tier. At Optum, we have “staying healthy,” which is the lifestyle group. Then, you have the “getting healthy” — the individuals who have not been diagnosed yet with an acute condition, but are on the verge. That might be the population that I would start with: those with signs of a condition. They’re borderline Type 2 diabetics. Their BMIs rank them in the high category. They’re smokers. They experience other aspects of high blood pressure. From a medical cost savings perspective, you can have a great impact by addressing that population and establishing some wins. By addressing that population you could easily start to filter it down into your healthy population and make it more of a lifestyle activity with minimal change or impact to your overall program.

Healthcare Daily Data Bytes put at your fingertips each day a "Data Byte" from the healthcare industry — facts, figures, statistics and percentages on healthcare spending, costs, utilization and performance. You can also register for free access to Healthcare Daily Data Byte archives.

How prevalent are patient and member education programs, and which health areas are addressed by these efforts? How are healthcare organizations delivering health education, and who is the primary health educator? What is the chief impact of patient education programs, and how do organizations measure ROI from patient education efforts? The Healthcare Intelligence Network set out to answer these questions and others during its 2009 Patient Education and Outreach Benchmarks e-survey. This executive summary of responses from 134 healthcare organizations offers lessons in the value of educating patients and members about disease management and self-care.

Tobacco cessation is one of the most cost-effective activities an employer can implement to improve the health and productivity of their employees while reducing healthcare costs. A new report from the non-profit National Business Coalition on Health (NBCH) finds that health plans are playing an important role in administering smoking cessation benefits and encouraging physicians and other providers to focus on smoking cessation through education, tools and incentives.

Using data from the eValue8 Request for Information (RFI) tool, which examines current health plan performance for a variety of areas including tobacco cessation, the report illustrates how employers can leverage health plan services to help their employees to quit smoking. NBCH’s eValue8 is the nation's leading standardized RFI tool used by employers and coalitions to measure and compare health plan performance from more than 100 health plans and health insurers.

According to Dennis White, senior vice president for value-based purchasing, NBCH, “tobacco cessation is a complex issue for employers and health plans. There is a significant process from identification of individuals needing support to successful treatment. eValue8 findings show that 80 percent of health plans are adopting evidence-based benefit design and are incorporating counseling and the use of FDA-approved medication with positive results.”

The report illustrates the importance of active employer engagement in their own workplace programs. Employer activities, including the development of programs and policies and the design of health benefits, augment those of the health delivery system. With the evidence of both the cost impact of tobacco use and the successful design for support programs for cessation, employers can work in collaboration with health plans to promote this benefit and the related policies and communications.

Healthcare reform, a fragile economy, high numbers of uninsured, the lingering threat of H1N1 and emerging care models are just a few factors that promise to drive changes in the healthcare industry in the coming year. To learn how other healthcare organizations are preparing for 2010, complete HIN's fifth annual survey on Healthcare Trends in 2010 by October 31 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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